Book Review: Living with Dying: The Management of Terminal Disease

The names of Dame Cicily Saunders and St. Christopher's Hospice are familiar to all who are concerned with care and treatment of the dying. This book is the product of many years of monitored clinical practice and research at that Hospice. The work is intended, in the first place, as a handbook for family and hospital doctors and for hospice physicians and nurses . However, there is much here which will be of great value for patients , family members , chaplains and social workers. Indeed, since any reader knows that she or he may well be, one day, in the position of the patients referred to, it is a book for everyone. In keeping with its purpose as a handbook for physicians and nurses, the text has three major sections on the use of analgesics for terminal pain; adjuvant therapy in pain control and the control of symptoms other than pain. These sections are addressed to the medical expert. However, the whole focus is patient-centered. As the authors write in the preface, the achievement that is looked for will be the patient's own. This achievement is the living of life to its full potential, even in dying. The development of skills in physical care is directed to making this possible in a situation of physical ease and activity, with assured personal relationships. The authors hold the view that the vast majority of cancer patients and those suffering from other diseases, could be given relieffrom terminal pain by the use of narcotic analgesics and other drugs. On the basis of their experience and research, they indicate in considerable detail what appropriate treatment is available. However, the treatment is constantly seen as in the service of helping the patient to accept responsibility for the life that remains to him or her. While the authors do not expressly argue the case against the deliberate shortening of life, they take a clear stand against this . The quality of living which can be achieved even in dying is seen as the most powerful argument against euthanasia. This quality can reflect a personal maturity and an intensified capaciti'to resolve relational and spiritual problems. Besides dealing with physical pain, the authors address mental pain, social pain and spiritual pain. Here, too, no doubt on the basis of experience, they have much to offer which will be of great value. Although the work is relatively brief, its recommendations are succinct and specific. The work does not argue the case for any specific religious belief system, and accepts the reality that many patients will not share a religious view or express themselves in religious terms. However, the authors indicate, again on the basis of actual experience, how certain beliefs, e.g., that life continues in some way beyond death, persist and support persons in the last crisis. Chaplains are cautioned against inappropriate intrusion, but are alerted to the (surprising) welcome which may be given to informal availability. There is extensive and detailed information on treatment for the professional. But there is something for all. The authors sum this up: the command "Watch with me" did not mean "take this crisis away" or much less "explain it." It simply meant, "Stay there and stay awake." Both for its professional information and deep humanity, this book is to be highly recommended.


l8o
Dr. Heberden, on the History of Diseases* [Review* Our limits will not allow us to examine every fubjett of thefe Commentaries rand, indeed, as difpaffionate judgement is the prevailing chara&er of the work, we meet with feveral fe&ions, in which the obfervations which they contain are valuable rather by adding a refpedtable teftimony to the efficacy of the general mode of pra&ice, than by introducing any new improvement. The firft fedtion is on the fubjedt of diet, a fubjeft which has at all times been much more attended to in other countries than in this,[and on which very little ftrefs is laid by prefent practitioners. Some of our Author's obfervations we (hall give to our readers. " Many phyficians appear to be too ftri?t and particular in the rules of diet and regimen which they deliver as proper to be obferved by all who are folicitous either, to preferve or recover their health. The common experience will fufficiently acquaint one with the forts of food which are wholefome to the generality of men. Whether meat fhould be boiled or roafted, or dreffed in any other plain way, and what fort of vegetables fhould be eaten with it, I never yet met with any perfon of common fenfe (cxcept in an acute illnefs) whom I did not think much fitter to choofe for himfelf than I was to determine for him." The author then gives a few (and a very few) rules for diet in fever. For drink in this difeafe he allows water, either warm or cold, at the option of the fick perfon, and only in fuch quantity as is agreeable to him.
The ratio meder.ai is treated of in the fecond chapter, and we cannot forbear giving briefly the indications laid down by the author, as we believe they are (in fad) fuch as generally diredt the operations of the phyiician. The firft confideration in the cure of difeafe is, whether it requires any evacuation, and what? zdly. Whether it be a diftempcr for which any fpecific has been found out ? Here the author adds fome remarks on the uncertainty attending this opinion, but thinks that the title of a fpecific may juftly be retained by bark for the cure of agues, quick-filver for venereal diforders, fulphur for the itch, perhaps opium for fome fpafms, and Bath waters for the injury done to the ftomach by drinking. 3dly. Vomiting, purging, pain, and other troublefome fymptoms, are often fo urgent as to require immediate relief, for . which opium is commonly the moft effectual means. 4thly. In long and obftinate difeafes, which have refilled particular remedies, recourfe muft be had to the means of generally affedting the fyftem, as by mercury, antimony, hemlock, and electrification. Laftly, where there is room for nothing elle, the phvfician mult fupport the power of life by ftrengthening the appetite, providing'for proper evacuations, &c.
The remarks on angina and scarlet fever are valuable for the accuracy of obfervation, and judicious diredtions. The author is decidedly of opinion that the fcarlet fever and the malignant fore throat are one and the fame diforder, and require exactly the fame method of treatment; regard being had to the local affeftion of the throat, fo much more i'evere in the latter than in the former diftemper. In the mode of treatment, the author fpeaks doubtfully of blood-letting, but highly in favour of bliiiers, which, he fays, the patient fhould neve? never be without, until he be out of danger. We were rather furprized to find no notice taken of emetics, which are certainly much employed, and are recommended in the higheft terms by an excellent writer on this difeafe, the la'.e Dr. Withering. The chapter on gout is pregnant with good fenfe and found observation, and the author very fuccefsfully combats i'ome of the popular notions concerning this dreadful malady, which have rendered it " the favourite difeafe of the prefent age in England, wifhed for by thofe who have it not, and boafled of by thofe who fancy they have it, though very fincerely lamented by moll who in reality fufter its tyranny." The author likewife takes occafion to introduce fome of thofe medico-moral obfervations which fo naturally fpring from the confideration of certain difeafes, and which flow with peculiar grace from the pen of a venerable and moll refpedlable writer, himfelf diflinguifhed for temperance, whofe long and extenfive experience entitle him to the higheit attention.
The author never faw a cafe of hydrophobia from the bite of a mad animal, a ftriking proof of the comparatively rare occurrence of this difeafe.
Confiderable attention appears to have been bellowed on the article ileus, or injlam~ mation of the bowels, one of the moft formidable of the catalogue of common difeafes, and one in which very much may often be efFedted by the power of medicine. " The peculiar and diftinguifhing fymptom which charadterifes the inflammatory colic in. the very beginning," the author obferves, " is a coftivenefs, which it is always extremely difficult and too often impoffible to conquer. As foon as a difcharge downwards can be procured in a copious manner, the patient perceives a quick abatement of all his mifery, and is foon reftored to health." He goes on to obferve, that the evacuation muft be complete, and points out the caufes of fallacy in trufting to an imperfedt evacuation which fometimes fupervenes. For the treatment, befides avoiding heating things, applying blifters, fomentations, and above all things ufing purgative medicines, the author ftrongly recommends clyfters of tobacco fmoke, to controul the irregular adlion of the bowels, and force them to empty their contents in a natural manner. The ufe of opium in this malady has been much controverted, and the author ftates the advantages and objedlions in a very candid manner. He is ftrongly in favour of their ufe. " Under the protection of an opiate," he obferves, " I have fuccefsfully given more and ftronger purges than would have flayed without its help ; the patient's llrength has been kept up by fome refrefhing fleeps ; and even in hopelefs cafes, in which the dying perfon is harrafled by unfpeakable inquietude, he may be lulled into fome compofure; and without dying at all fooner, he may be enabled to die more eafily." A caution of high importance is given under the article Hypochondriacus ajfeSus. " Many," he obferves, " in a lownefs of fpirits, are not indifpofed to raife them by wine and fpirituous liquors, and they are encouraged and prefled to do it by their wellmeaning but ill-judging friends. No words can be too llrongjto paint the danger of fuch a pra&ice in its proper colours. The jS 3 momentary Mr. Lee> on Cow-Pox Inoculation. [Review.
momentary relief is much too dearly bought by the far greater languor which fucceeds ; and the neceffity of increafing the quantity of thefe liquors, in order to obtain the fame effect, irrecoverably ruins the health, and in the moft miferable manner." The author much prefers opium as a cordial. " My own experience," he adds, " has often taught me how fafely and confidently with bufinefs a courfe of opium may be continued for a confiderable part of man's ljfe, and how practicable it is to be weaned from the habit of it." We (hall only add, to our review of this valuable work, that we apprehend moft of thofe who perufe it will regret that feveral fubjedts of importance are difmified with a few curfory obfervations, where fuller particulars of the practice of the late author would have been peculiarly acceptable. We cannot, however, make this any reafonable ground of complaint, as nothing like a fyftematicaj defcription of difeafes is at all intended to be given, and the Writer excufes himfelf from not having done more in a life of fifty years experience, partly for reafons which will only be attributed to his modefty, and partly from the very flow progrefs which is ever made in the fcience of medicine, and the almoft infuperable obilacles which oppofe our fuccesful refearch into the nature of organized life ; with which defponding fentiment the Author takes his leave of the public. * Fads, and some Arguments, tending to shew that the public Decision may 'with prudence be suspended respecting Inoculation cf the Ccruj-Poxi by Thomas Lee, a Member of the Univerfity of Edinburgh, 8vo. pp. 36. The title of the pamphlet before us fufficiently expreffes its contents, namely, to throw a doubt on the inferences drawn from tfye numerous teftimonies concerning the Cow-pox, which have lately been made the fubje?t of difcuflion by the medical world in almoft every part of the globe, and in our own country by a feledt body of the Legiflature. After fome remarks on the importance of the queftion concerning the efficacy of the Cow-pox, the author makes the following obfervations: " The decifion of a parliament fhould be revered by the people ; but parliament, like a jury, can only decide upon evidence ; and if the evidence be all one way, of one tenor, can a parliament be blamed, or a jury arraigned, for giving a judgment contrary to the real fa?t ?" He then adverts to what is doubtlefs a fadt, that " parliament largely rewarded ap old woman for the fecret of difguifing foap in veal broth, as a never failing folvent of ftone in the bladder, and yet the ftone ftill torments mankindand that, " the direful tape worm ftill infefts us, although Mrs. Bouffiers was penfioned and ennobled for communicating a nonfenfical noftrum, which fhe pretended would effectually deftroy it." As we differ confiderably in opinion from the Author before us, we beg to obferve in the firft place, that the late examination before a Committee of the Houfe of Cpmmons on Dr. Jenner'a Review.] Mr. Lee, on Cow-poxlnoculation, ncr's petition, was conducted neither haftily nor partially ; that every pains was taken to procure as great a body and variety of evidence as the cafe could admit of; and that if the teftimony there given made fuch a vaft preponderance in favour of Dr. Jenner's difcovery, it furely is to be attributed to fomething more than private friendfhip or the falhion of the day. The cafes of Mrs. Stephens's medicine and Mrs. Bouffler's fern powder are not exattly fimilar, becaufe being profefledly fecrets in the hands ?f the claimants, their merits could not be fo open to inveftigation of every kind, as in the cafe of the Cow-pox, where vaccine inoculation had been already tried with fuccefs over a very large fpace of country, and where all the arguments, from analogy as well as attual experience, had already been repeatedly canvaffed. And after all, Mrs. Stephens's medicine (whatever might be her claim) was really found to be of ufe in relieving the dreadful complaint of the ftone, and is ftill employed, under one form or other, with frequent fuccefs.
The author then reprefents the great enthufiafm which was excited by the introduction of inoculation for the fmall-pox, and the high expe&ations to which it gave rife?" The divine, the orator, and the phyfician, the eloquent, and the fcientific, alike interefted themfelves, and difplayed their abilities in the caufe of humanity, and the grand jury of Europe pronounced inoculation of the fmallpox to be a benefit to the human race. But this benefit has proved a phantafma, an illufion merely; the annals of mortality, through half a century, {hew it to be all illufion; and that moll obvious direfui impediment to human increafe is ftill unchecked and at large, laughing to fcom the power of man, and triumphing in its career of peftilential malignity. Now inoculation of the Cow-pox has ufurped the language, and proffers to realize the hope which her elder After fo vainly encouraged, and this beast is faid to work that miracle which man has failed to accomplifh." We have given here the author's words, as it is right that the favourers of vacr cine inoculation fhould know the mode in which their opinions are combated; but, in fober ferioufnefs, we would beg to ask the author, where was the error committed in adopting fmall-pox inoculation with the zeal and enthufiafm with which its firft promoters favoured its claims? The precife objections that are now urged againft the Cow-pox were advanced with ftill more warmth againft variolous inoculation. In particular, it was aflerted to be a new and dangerous difeafe, and that it failed in giving a permanent fecurity againft the contagion of the difeafe caught in the natural way. And has not it flood the teft of long experience, and rifen triumphantly above all the attempts to injure its intrinfic worth? Is not the security which it affords, moft completely eftablifhed ? And has not the celebrated female who introduced it into Europe, a. high claim on the gratitude of thofe who, by its means, have at a cheap rate been delivered from the danger of a moft loathfome and deftruttive difeafe? It is undifputed, however, that the mortality arifing from the fmall-pox, in the aggregate, hasincreafed fin<:e, and by the introduction of inoculation; and even to fuch a degree as Mf fomc [Review.
?Tome years ago to have prevented its adoption into France after mature confideration. But will it be faid that fuch a wonderful benefit to all individuals who chofe to partake of it, Ihould not have been patronized and adopted on its firft introduction, becaufe the legiflature ought to have forefeen that the prejudice, obftinacy, and blindnefs of the great mafs of people would, perhaps for centuries, reje& the proffered boon ? Hovyever, be it fo; at leaft, the Cowpox, this beast (as the author terms it, with equal elegancy and propriety) is proved without any difpute to be free from that infectious nature which unfortunately rendered her elder sister fo dangerous to all but her immediate friends, though of human nature.
The more fober part of our author's treatife, however, contains fome theoretical objections to the probability of the permanent efficacy of vaccination, which, we think, he has himfelf fufficiently anfwered in the next page by the fingle obfervation, " that we are too little acquainted with the phyfiological or chemical conformation of the human conftitution to be able to draw any juft conclufion from the analogy." Fails follow next, and to thefe we would wifh to pay every attention. Two, in oppofition to the efficacy of the Cow-pox, are alledged; the firft, a declaration of one Robert Newman, whom the author reprefents as a very refpeflable man in a humble fphere of life, that he had the Cow-pox in Gloucefterfhire when young, and afterwards took the fmall-pox feverely by inoculation. The fecond is the cafe of a young woman, who early in life had an eruption of a few puftules on her fingers when employed milking cows, which was then and there called the Cowpox, who afterwards had feveral times refilled the fmall-pox, but at laft caught it in a very fevere form. We do not doubt of the fairnefs of the ftatement on the part of the author, but we hardly think it neceffary here to point out feveral circumftances which might be fuggefted upon thefe reprefentations. Thequeftion of the eligibility of the Cow-pox is before the public, the experiments are going on, on a very large fcale, and our pofterity will judge accordingly. The author concludes thi3 pamphlet with a propofal, that in every hundred parifhes in the kingdom, ten fubjedts fhould be feledted for experiment with the Cow-pox; that the magiftrates, &c. fhould examine in perfon the operation and the authenticity of the reports; that Dr. Jenner fhould be retained at an ample falary as an InfpeCtor General, &c. &c.; in fhort, that the government of the country fhould take it up as a national concern, and condutt the experiment with the weight of their authority.^ We have but two objections to make againlt this plan ; the one, its utter impractibility, or, at leaft, the high improbability that it fhould continue for years to be conduced with the requifite care and attention; and the other, that the experiment is actually carrying on at an infinitely greater extent, by perfons who have the powerful motive of private character and reputation to prevent them from attempting any fyllematical plan of impofing on the public, to whofe final determination the whole bufinefs will and must be fubmitted. cities'T they dreadfully overbalance many of the natural advantages for commerce and defence, poffe/Ted by feveral of the moft important fettiements; they fpread alarm, terror, and confufion, whereever they appear, and oppofe the exercife of one of the moft important of the focial duties, by rendering the attendance on the lick either an heroic facrifice to affedtion, which few can make, or a mercenary fervice which muft be made amply to repay the perfonal rifk-Few fubjefts, therefore, have a greater claim to public and national attention, than the difcovery of any mode of Ieffening or preventing thefe formidable evils; and thefenfe of common danger has induced the governing powers of almoft every civilized country, from the earlieft ages, to eftablifh regulations (more or lefs fevere according to the exigency of the cafe) in order to prevent the fpreading of infeftious difeafe.
We have no hefitation in afTerting, that the method of fumigation with the vapour of the more powerful acids affords a moft important corrective of infe&ion, the value of which has already been afcertained by numerous and extenfive trials, and is therefore deferving of the higheft attention.
The objett of the author in the work before Us, is to examine into this fubjeft at large, to aflert his claim to a priority of difcovery, by inconteftable proofs, and to eftablifh the fuperiority of the muriatic acid over other fubftances of afimilar nature, which have been employed in different trials. The hiftory of the difcovery and employment of acid vapours in checking infection is curious. The ufe of fumigations of almoft every kind of combuilible fubllance, is a pradlice of great antiquity, and has formed a regular part of the prattice in various Hofpitals and Lazarettoes for the plague for many centuries: even the vapour of vinegar appears to have been long employed, and the tranfition from thefe fubllances to the ufe of the mineral acid vapours, appears fo obvious, that we may be furprized that it had remained fo long undiscovered. The late Dr. Johnftone ofWorcefter, (a man of a very acute mind, and a warm zeal for the improvement of his profefiion) was certainly the iirft who is known to have employed the vapour of the muriatic acid in corre&ing (very fuccefsfully) the contagion of a very malignant fever which had appeared at Kidderminfter in 1756, and had Ihewed fuch peculiar virulence, as to have acquired the name of " the Kidderminfter fever." * This folitary fa6t, though fo important, was foon negle?led, and nothing more appeared on thefubjeft, till in the year 1773, M. Morveau-Guyton employed the fame acid to fumigate the cathedral church of Dijon, which had been made infupportably infe&ed by the putrefa&ion of a number of corpfes which it was necefl'ary to remove ; and alfo, in the fame, year, a few months afterwards, the fame eminent cheitiift repeated the fumigation in the jails of Dijon, which were then infefted * Dr. Johnftone publiftied an account of this fever, and th? mode of fumigation, in a Treat ife, entitled An Hiftorical Difiertation on the Malignant Fever which vaiied at Kidderminfter, in I7j<.
Review.] Morveaus Treatise on purifying infected Air. 287 infeCted with a very malignant fever. It will be .proper to obferve here, that we can fcarcely entertain any doubt that this celebrated chemift and excellent philofopher propofed this method of fumigation from his own reafoning on the fubjeCt; for the Journals and other publications of that time {hew, that the properties of the muriatic acid gas were then engaging the attention of the chemical world ; and the {Inking experiment of its union with, and thereby neutralizing ammoniacal gas, had often been performed. Now, as ammonia was then known to be difengaged by putrefaction, it was certainly a highly ingenious idea of this chemift to let loofe in putrefying air a quantity of muriatic acid gas, in order to cor-reCt the ammonia, in the production of which the putrid procefs Was thought principally to confift.
In 1774, the muriatic fumigation (which had hitherto made but little progrefs) was employed, at the recommendation of the late Vicq d'dzyr to purify {tables from the infection of a very destructive malady, which, at that time, proved fatal to a vaft number of cattle in the fouth of France. In 1780, the Academy of Sciences, (who had been confulted by government on the belt means of correcting the infalubrity of prifons), appointed a committee for this purpofe, compofed of Meffrs. Dubamel, De Montigny, Lsroi, Tenon, Tillet, and Laveisjer, all men of high reputation and ability, who, among other means, recommend in ftrong terms, the method of muriatic fumigation fo fuccefsfully employed by M. Morveau.
Still, however, the progrefs made in the general introduction of this fumigation was very flow and imperfeCt; but the dreadful epidemic at Genoa in 1799, and the ftill more fatal and extenfive malady which foon after ravaged Andalufia, and efpecially the town of Cadiz, (which our readers will recoiled, from the circumftance of its being then blockaded by the Britifh Fleet) obliged the governments to have recourfe to every vigorous means of correcting the infection, and, among thefe, the muriatic fumigation was employed with eminent advantage.
The author of this treatife proceeds to notice the very important experiments made in this country, by defire of the Lords of the Admiralty, with the nitrous acid vapour, on board the Union Hofpical {hip in Nov. 1795, to correCt the contagion of a very malignant fever, which had made great ravages on board the Ruffian {hips at Sheernefs. The trial of this acid vapour was made, (as our Readers muft well know), at the fuggeltion of Dr. Carmichael Smyth;. and the fuccefs was fo complete, as to leave no reafon to doubt of the high efficacy of this fumigation. Subfequent trials have confirmed this opinion, and have induced the Houfe of Commons to vote a reward to Dr. Smith, for this valuable and eafy method of deftroying the contagion of infectious fevers.
In the third feCtion of this very interefting work, M. Guyton introduces a number of comparative experiments, made with a view of determining what fubftances are the molt effectual in correcting the fetor of air in which meat has long putrified. For the particulars of thefe valuable experiments we muft refer the reader to the work itfelf, as well as for feveral chemical arguments which cannot be eafily given in a condenfed form. Suffice it to fay, that the various odorous refins, &c. burnt in the infe&ed air, produced re other efFeft than imperfe&ly to conceal the fetor of the air itfelf, and this fully eftablilhes the opinion (which indeed is now generally received) that merely to fcent an infeftious air with any iirong perfume, takes away none cf its noxious properties, and in general, does much harm in hofpitals, and other large fources of infeftion, by rendering the offenlive fmell for a while tolerable, and therefore often fupplying the place of thorough ventilation, or the more powerful fumigations, which appear adtually to dejlroy the fetid particles by chemical combination. Of this latter kind of fumigation are all the acid vapours. The acid gafes employed in the experiments were, the fulphureous, the nitric, the muriatic, and the oxygenated muriatic, and the power of the three latter by far exceeded that of the former. The author then attempts to mftitute a comparifon between thefe three acids, with regard to the power which theypoflefs in corre&ing infe&ious air. We cannot fay that he has eftablifhed, in a very fatisfattory manner, the point which he endeavours to prove, namely, the fuperior efficacy of the muriatic and the oxygenated muriatic acids over the nitrous.
The difficulties which lie in the way of fuch a comparifon are very great and obvious, and probably it would require the experience of many years to eflablifh the point. The author lays fome ftrefs on the circumftance, that Dr. Smyth thought it proper to fumigate much oftener with the nitrous vapour, than the French and Spanifh phyficians did with the muriatic. But it is evident, that in neither cafe could it be at all inferred, boiu much of the vapour was requifite; and where the method of employment is fo cheap and eafy of application, no great harm can arife from excefs of precaution, at all comparable to the confequences of negleft. A more valid argument in favour of the muriatic acid is its much greater diffusibility than the nitrous, and its requiring a much lefs heat to be expelled in a gafeous form from the mixture of oil of vitriol and fait, than the nitrous, from oil of vitriol and nitre. However, it is by no means necefiary to determine a preference between the two, fince the anti-putrefcent powers of both are fo very powerful and extenfive, that either of them may be reforted to with the higheft confidence of fuccefs, and we earneftly wilh to fee this method of fumigation enjoined in every jail, hofpital, and fever houfe in the kingdom, where the virulence of infection refills the common methods of ventilation and cleanlinefs, A confiderable part of this work is taken up with an attempt to extend the fuppofed operation of oxygen upon the animal fyftem to a great variety of circumftances; and in the true fpirit of modern chemiftry, to explain the operation of medicines, and the effect of morbid caufes, by the laws of chemical affinity, which are afcertained in the laboratory. We lhall not trefpafs on our Readers time by detailing every crude notion and vague conjecture to which this method of philofophizing on the laws of the living animal has given rife. In the inftance before us, we owe fo much to the strength of cljgmiftry that we {hall forbear to expofe its weakness. ? Medical